e84 IMAGE OF THE MONTH CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 10, No. 10mass but also no evidence of hypervascularity either in the vival beneﬁt. With the efﬁcacy of sorafenib and transarterialparenchymal mass (Figure D, arrow) or the inferior vena cava/ chemoembolization in systemic and locoregional disease con-right atrial tumor thrombus (Figure E, arrow). The patient trol, a combined treatment approach offers potential new mo-remains asymptomatic at 1 year with no further evidence of dalities in treating patients with a dismal prognosis.3,4viable tumor, metastatic disease, propagation of tumor intopulmonary vasculature, or ﬁndings from chronic liver disease,and he remains on sorafenib. References Hepatocellular carcinoma, the ﬁfth most common cancer 1. El-Serag HB, Mason AC. Rising incidence of hepatocellular carci- noma in the United States. N Engl J Med 1999;340:745–750.worldwide, is the fastest growing cause of cancer-related deaths 2. Marrero JA, Fontana RJ, Barrat A, et al. Prognosis of hepatocellularin the United States.1 Vascular invasion including malignant carcinoma: comparison of 7 staging systems in an American cohort.tumor thrombus in the portal vein or hepatic vein/inferior vena Hepatology 2005;41:707–716.cava occurs in 31% to 38% of patients at initial presentation.2 3. Llovet JM, Real MI, Montaña X, et al. Arterial embolisation or che-The prognosis for patients with vascular invasion is dismal, moembolisation versus symptomatic treatment in patients with un-with the median overall survival generally less than 7 months.2 resectable hepatocellular carcinoma: a randomised controlled trial.Traditionally seen as a harbinger for systemic spread, treatment Lancet 2002;359:1734 –1739.for vascular invasion of the hepatic venous/inferior vena cava 4. Llovet JM, Ricci S, Mazzaferro V, et al. Sorafenib in advanced hep-system has relied on systemic chemotherapy with limited sur- atocellular carcinoma. N Engl J Med 2008;359:378 –390.